Case Study: A Patient With Type 2 Diabetes

Working With an Advanced Practice Pharmacist

to Address Interacting Comorbidities
1. Peggy Yarborough, PharmD, MS, BC-ADM, CDE, FAPP, FASHP, NAP
Diabetes Spectrum 2003 Jan; 16(1): 41-48. https://doi.org/10.2337/diaspect.16.1.41

PreviousNext

 Article

 Figures & Tables

 Info & Metrics

 PDF

Advanced practice pharmacists in the field of diabetes work collaboratively with patients’ medical providers,
often in primary care settings or in close proximity to the providers’ practices. They help to integrate the
pharmaceutical, medical, education/ counseling, and direct patient care activities necessary to meet patients’
individual self-management and diabetes care needs.

Patient education and self-management behavioral change are underpinnings of pharmaceutical care, and not
only as they directly relate to the use of medications. Pharmacists, especially those who are certified diabetes
educators (CDEs), frequently provide diabetes patients with education not only on medications, but also on the
overall disease state, nutrition, physical activity, decision-making skills, psychosocial adaptation, complication
prevention, goal setting, barrier resolution, and cost issues.

In addition to these substantial education responsibilities, advanced practice pharmacists who are Board
Certified–Advanced Diabetes Managers (BC-ADMs) play an expanded role that encompasses disease state
management. This includes performing clinical assessments and limited physical examinations; recognizing
the need for additional care; making referrals as needed; ordering and interpreting specific laboratory tests;
integrating their pharmacy patient care plans into patients’ total medical care plans; and entering notes on
patient charts or carrying out other forms of written communication with patients’ medical care providers.
Depending on state regulations and physician-based protocols, some advanced practice pharmacists can
prescribe and adjust medications independently or after consultation with prescribing clinicians.

The clinical activities of BC-ADM pharmacists are not carried out independent of referring, collaborative
practitioners. Rather, they are complementary to and serve to enhance the diagnostic, complex physical
assessment, and management skills of medical providers.

The following case study illustrates the pharmacotherapeutic challenges of diabetes with other comorbidities,
which can lead to potential drug-drug and drug-disease interactions. Although it does not offer detailed
solutions to such problems, this case does describe the process of patient care and problem resolution as
approached by advanced practice pharmacists.
 Case Presentation

B.L. is a 58-year-old white woman who has been referred to the pharmacist clinician for pharmacotherapy
assessment and diabetes management. Her multiple medical conditions include type 2 diabetes diagnosed in
1995, hypertension, hyperlipidemia, asthma, coronary artery disease, persistent peripheral edema, and
longstanding musculoskeletal pain secondary to a motor vehicle accident. Her medical history includes atrial
fibrillation with cardioversion, anemia, knee replacement, and multiple emergency room (ER) admissions for
asthma.

B.L.’s diabetes is currently being treated with a premixed preparation of 75% insulin lispro protamine
suspension with 25% insulin lispro preparation (Humalog 75/25), 33 units before breakfast and 23 units before
supper. She says she occasionally “takes a little more” insulin when she notes high blood glucose readings, but
she has not been instructed on the use of an insulin adjustment algorithm.

Her other routine medications include the fluticasone metered dose inhaler (Flovent MDI), two puffs twice a
day; salmeterol MDI (Serevent MDI), two puffs twice a day; naproxen (Naprosyn), 375 mg twice a day;
enteric-coated aspirin, 325 mg daily; rosiglitazone (Avandia), 4 mg daily; furosemide (Lasix), 80 mg every
morning; diltiazem (Cardizem CD), 180 mg daily (per cardiologist consult); lanoxin (Digoxin), 0.25 mg daily
(per cardiologist consult); potassium chloride, 20 mEq daily; and fluvastatin (Lescol), 20 mg at bedtime.
Medications she has been prescribed to take “as needed” include sublingual nitroglycerin for chest pain (has
not been needed in the past month); furosemide, additional 40 mg later in the day if needed for swelling (on
most days the additional dose is needed); and albuterol MDI (Proventil, Ventolin), two to four puffs every 4–6
hours for shortness of breath. She denies use of nicotine, alcohol, or recreational drugs; has no known drug
allergies; and is up to date on her immunizations.

B.L.’s chief complaint now is increasing exacerbations of asthma and the need for prednisone tapers. She
reports that during her last round of prednisone therapy, her blood glucose readings increased to the range of
300–400 mg/dl despite large decreases in her carbohydrate intake. She reports that she increases the frequency
of her fluticasone MDI, salmeterol MDI, and albuterol MDI to four to five times/day when she has a flare-up.
However, her husband has been out of work for more than a year, and their only source of income is her Social
Security check. Therefore, she has been unable to purchase the fluticasone or salmeterol and so has only been
taking prednisone and albuterol for recent acute asthma exacerbations.

B.L. reports eating three meals a day with a snack between supper and bedtime. Her largest meal is supper. She
states that she counts her carbohydrate servings at each meal and is “watching what she eats.” She has not been
able to exercise routinely for several weeks because of bad weather and her asthma.

The memory printout from her blood glucose meter for the past 30 days shows a total of 53 tests with a mean
blood glucose of 241 mg/dl (SD 74). With a premeal glucose target set at 70–140 mg/dl, there were no
readings below target, 8% within target, and 91% above target. By comparison, her results from the same
month 1 year ago averaged 112 mg/dl, with a high of 146 mg/dl and a low of 78 mg/dl.

Physical Exam

B.L. is well-appearing but obese and is in no acute distress. A limited physical exam reveals:

 Weight: 302 lb; height 5′1″

 Blood pressure: 130/78 mmHg using a large adult cuff

 Pulse 88 bpm; respirations 22 per minute

 Lungs: clear to auscultation bilaterally without wheezing, rales, or rhonchi

 Lower extremities +1 pitting edema bilaterally; pulses good

B.L. reports that on the days her feet swell the most, she is active and in an upright position throughout the
day. Swelling worsens throughout the day, but by the next morning they are “skinny again.” She states that she
makes the decision to take an extra furosemide tablet if her swelling is excessive and painful around lunch
time; taking the diuretic later in the day prevents her from sleeping because of nocturnal urination.

Lab Results

For the sake of brevity, only abnormal or relevant labs within the past year are listed below.

 Hemoglobin A1c (A1C) measured 6 months ago: 7.0% (normal range: <5.9%; target: <7%)
 Creatinine: 0.7 mg/dl (normal range: 0.7–1.4 mg/dl)

 Blood urea nitrogen: 16 mg/dl (normal range: 7–21 mg/dl)

 Sodium: 140 mEq/l (normal range: 135–145 mEq/l)

 Potassium: 3.4 mg/dl (normal range: 3.5–5.3 mg/dl)

 Calcium: 8.2 mg/dl (normal range: 8.3–10.2 mg/dl)

 Lipid panel

• Total cholesterol: 211 mg/dl (normal range <200 mg/dl)

• HDL cholesterol: 52 mg/dl (normal range: 35–86 mg/dl; target: >55 mg/dl, female)

• LDL cholesterol (calculated): 128 mg/dl (normal range: <130 mg/dl; target: <100 mg/dl) Initial LDL
was 164 mg/dl.

• Triglycerides: 154 mg/dl (normal range: <150 mg/dl; target: <150 mg/dl)

 Liver function panel: within normal limits

 Urinary albumin: <30 μg/mg (normal range: <30 μg/mg)

Assessment

 Poorly controlled, severe, persistent asthma

 Diabetes; control recently worsened by asthma exacerbations and treatment

 Dyslipidemia, elevated LDL cholesterol despite statin therapy

 Persistent lower-extremity edema despite diuretic therapy

 Hypokalemia, most likely drug-induced

 Hypertension JNC-VI Risk Group C, blood pressure within target and stable

 Coronary artery disease, stable

 Obesity, stable

 Chronic pain secondary to previous injury, stable

 Status post–atrial fibrillation with cardioversion

 Status post–knee replacement

 Financial constraints affecting medication behaviors

 Insufficient patient education regarding purposes and role of specific medications

 Wellness, preventive, and routine monitoring issues: calcium/vitamin D supplement, magnesium supplement,
depression screening, osteoporosis screening, dosage for daily aspirin

Discussion

Strand et al.1 proposed a systematic method for evaluation of and intervention for a patient’s pharmacotherapy,
using a process called the Pharmacist’s Work-Up of Drug Therapy (PWDT). The PWDT has been modified by
subsequent authors,2–4 but the process remains grounded in the following five questions:
1. What are reasonable outcomes for this patient?

2. Based on current guidelines and literature, pharmacology, and pathophysiology, what therapeutic endpoints
would be needed to achieve these outcomes?

3. Are there potential medication-related problems that prevent these endpoints from being achieved?

4. What patient self-care behaviors and medication changes are needed to address the medication-related
problems? What patient education interventions are needed to enhance achievement of these changes?
5. What monitoring parameters are needed to verify achievement of goals and detect side effects and toxicity, and
how often should these parameters be monitored?

Outcomes and Endpoints

Clinical outcomes are distinctly different from therapeutic or interventional endpoints. The former refers to the
impact of treatment on patients’ overall medical status and quality of life and should emphasize patient-
oriented evidence that matters (POEMs) rather than disease-oriented evidence (DOEs).

Therapeutic endpoints include the anticipated and desired clinical effects from drug therapy that are expected,
ultimately, to achieve the desired outcome(s). As such, therapeutic endpoints are used as surrogate markers for
achievement of outcomes. Commonly, more than one endpoint will be needed to achieve an outcome. For
example, near-normal glycemic control and normalization of blood pressure (endpoints) would be necessary to
significantly reduce the risk of end-stage renal disease (outcome).
Therapeutic endpoints should be specific, measurable, and achievable within a short period of time.
Achievement of clinical outcomes usually cannot be determined except by long-term observation or
retrospective analysis.

Outcomes and endpoints for any given patient should be determined collaboratively between patient and
provider before selecting or initiating pharmacotherapy or nonpharmacological interventions. Taking the time
to identify these components up front (and periodically revise them later on) helps ensure that subsequent
medications or strategies are appropriately directed. It further ensures a common vision and commitment for
ongoing patient care and self-management among the care team (including the patient), thus maximizing the
potential for optimal disease control and patient satisfaction.

The outcomes and endpoints for a patient such as B.L. are numerous and obviously would not be addressed or
attained in a single session. Therefore, after desired outcomes and endpoints are determined, they should be
prioritized according to medical urgency and patient preference. Implementation and goal setting related to
these priorities can then be undertaken, thus establishing a treatment plan for the eventual attainment of the full
list.

During ongoing and follow-up visits, this care plan should be reviewed and modified as indicated by changes
in patient status, preferences, and medical findings. Examples of desired outcomes and endpoints for B.L. are
given in Tables 1 and 2. For the sake of brevity, these tables are not intended to be inclusive.

Medication-Related Problems and Proposed Interventions

With agreement between patient and clinician concerning desired outcomes and endpoints, the next logical
step is to evaluate whether the current treatment plan is likely to achieve those goals, or, if treatment is to be
initiated, which therapies or interventions should be selected.

According to Strand et al.,1 a medication-related problem is any aspect of a patient’s drug therapy that is
interfering with a desired, positive patient (therapeutic) outcome or endpoint. The PWDT proposes a
systematic and comprehensive method to identify, resolve, or prevent medication-related problems based on
the following major categories:
1. No indication for a current drug

2. Indication for a drug (or device or intervention) but none prescribed

3. Wrong drug regimen (or device or intervention) prescribed/more efficacious choice possible
4. Too much of the correct drug

5. Too little of the correct drug

6. Adverse drug reaction/drug allergy

7. Drug-drug, drug-disease, drug-food interactions

8. Patient not receiving a prescribed drug

9. Routine monitoring (labs, screenings, exams) missing

10. Other problems, such as potential for overlap of adverse effects

Once problems are identified, resolutions must be developed, prioritized, and implemented. Patient or
caregiver input is especially helpful at this stage because the individual can describe subjective as well as
objective data, expectations or concerns that may be affecting drug therapy, and deficits in drug knowledge,
understanding, or administration.

Resolutions may result from numerous strategies, including dose alteration, addition or discontinuation of
medication, adjunct medications, regimen adjustment, complementary therapies, instruction on medication
administration or devices, disease or medication education, development of “cues” as compliance reminders
(e.g., pill boxes), and identification of ways to avoid, detect, or manage side effects or toxicities. Needless to
say, the involvement of patients and family or caregivers is critical for successful implementation of most
resolution strategies and for optimal disease management.

Because of the extent of B.L.’s medication-related problems and potential interventions (Tables 3 and 4), it
was agreed to tackle first her asthma exacerbations and high blood glucose levels. To this end, B.L. was
counseled about the role of maintenance asthma medications versus rescue drugs. The root of her confusion
between these agents was easy to understand—because the prednisone and fluticasone were both called
steroids, it seemed likely that the tablets were a cheaper and easier way to take the medicine. Likewise, since
albuterol and salmeterol were both called bronchodilators, it seemed that the albuterol was the cheaper way to
take the medicine.
Having grasped the concept of asthma prevention, she was willing to convert to a product combining
fluticasone and salmeterol (Advair Diskus) for maintenance/prevention and to reserve the albuterol for quick
relief of acute symptoms. Free samples of the new product were dispensed, and B.L. was enrolled in the
manufacturer’s indigent drug program for subsequent supplies.

She was further instructed on the use of a peak flow meter and advised to monitor her readings and symptoms.
At the next visit, these data will be used to determine her maximal expiratory effort (“personal best”) and to
construct an asthma action plan.

B.L.’s insulin was changed to a basal-based regimen utilizing bedtime glargine (Lantus) insulin and premeal
lispro (Humalog) insulin. Education was provided on this dosing concept. She and the pharmacist discussed
how this regimen can give greater flexibility in dosing, especially for responding to changes in diet, exercise,
and disease exacerbations or medications. She was also given an initial supplementary adjustment algorithm
(sliding scale) to correct for any temporary elevation of blood glucose. She agreed to test four times daily and
to record her blood glucose results, carbohydrate intake, and insulin doses. At the next visit, these data will be
used to modify the adjustment algorithm and to construct a prospective algorithm for matching premeal bolus
insulin to the anticipated carbohydrate intake (insulin-to-carbohydrate ratio).
 The final interventions for this visit were to increase the dose of potassium chloride and change the fluvastatin
to atorvastatin (Lipitor) to further reduce B.L.’s LDL cholesterol. Medication education for atorvastatin was
provided, and patient questions were answered.

Other medication-related problems and interventions identified for B.L. are listed and briefly discussed
in Tables 3 and 4. For the sake of brevity, these lists are not inclusive nor are all pharmacotherapy issues
discussed.

Monitoring for Effectiveness, Side Effects, and Toxicity

The last step in the PWDT process is to develop a plan to evaluate the patient’s progress in attaining desired
outcomes, therapeutic endpoints, and behavior changes; to assess effectiveness of pharmacotherapy; and to
identify side effects, drug interactions, or toxicity issues that need to be addressed.

The monitoring/follow-up component is the most tedious aspect of the PWDT. For each medication or
intervention, key parameters must be identified as markers for effectiveness, for side effects, for drug
interactions, and for toxicity. In addition, the time frame and process for assessing those parameters must be
determined. Finally, the desired range for the parameter must be listed or a “decision point” must be identified
to signal that additional action will be required.

It should be noted that only a limited number of parameters are selected for a given patient. For example, it is
not necessary to list and monitor for every possible side effect with equal intensity and frequency. Selection of
the monitoring parameters is based on the positive effects (efficacy) that are most important to the care of that
patient, as well as the adverse effects (side effects, toxicity, or drug interactions) that are most important to
avoid for the safety of that patient or to which that patient is most prone.

Because the monitoring component is usually extensive, examples listed for B.L. in Table 5have been limited
to three of the medication or regimen changes that were made at the first pharmacist visit: switching from
fluvastatin to atorvastatin; switching from two shots of premixed 75/25 lispro to bedtime glargine with premeal
lispro; and substituting the combination inhaler product for her fluticasone and salmeterol MDI prescriptions.
Because atorvastatin and fluvastatin differ chemically, the monitoring parameters for this change are similar to
those for initiation of a new medication. Monitoring for the new insulin regimen (basal insulin with premeal
bolus) focuses primarily on glycemic control patterns and hypoglycemic episodes. Because B.L. has
previously used the two ingredients of her new inhaler product (fluticasone and salmeterol) without adverse
effect, monitoring of her new asthma therapy is focused on effectiveness, tolerance of inhalation of its dry
powder formula, and use of the administration device.

Summary

Diabetes patients with multiple co-morbidities have concerns about all of their problems, not just the diabetes;
therefore, BC-ADM pharmacists must comprehensively explore all the ramifications of comorbidities as well
as patients’ feelings, expectations, and concerns for total health. B.L. is a good example of this; even though
her referral was for “diabetes management,” her greatest concern at this visit was her asthma exacerbations.

As can be seen in this case, each coexisting disease or coprescribed drug has a domino effect, affecting other
diseases or drugs and ultimately affecting quality of life. With input from B.L., the pharmacist clinician was
able to develop a PWDT that addresses her diabetes as well as her other health care needs.

B.L. was able to leave the health center with a few achievable self-care goals and medication changes that
address her acute concerns and with the knowledge and confidence that, at each subsequent visit, additional
progress will be made toward her personalized health status goals.
  View inline
 View popup
 Download powerpoint
Table 1.
Examples of B.L.’s Desired Outcomes

 View inline
 View popup
 Download powerpoint
Table 2.
Examples of B.L.’s Therapeutic Endpoints

 View inline
 View popup
 Download powerpoint
Table 3.
Examples of B.L.’s Medication-Related Problems

 View inline
 View popup
 Download powerpoint
Table 4.
Examples of B.L.’s Interventions (Prioritized and to be Implemented Accordingly)

 View inline
 View popup
 Download powerpoint
Table 5.
Examples of B.L.’s Monitoring Plans

Footnotes

 Peggy Yarborough, PharmD, MS, BC-ADM, CDE, FAPP, FASHP, NAP, is a professor at Campbell University
School of Pharmacy in Buies Creek, N.C., and a pharmacist clinician at Wilson Community Health Center in
Wilson, N.C.

 For information concerning POEMs and DOEs: a multitude of literature on this topic is available through
Internet sources. Search for “patient oriented evidence that matters” using a medical topic browser.

 American Diabetes Association

 References

1. ↵
Strand LM, Morley PC, Cipolle RJ, Ramsey R, Lamsam GD: Drug-related problems: their structure and function. Ann
Pharmacother 24:1093–1097, 1990
PubMedGoogle Scholar

2. ↵
Hepler CD, Strand LM: Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm47:533–543, 1990
AbstractGoogle Scholar

3. Canaday BR, Yarborough MC: Documenting pharmaceutical care: creating a standard.Pharmacotherapy 28:1292–
1296, 1994
Google Scholar